[SPEAKER]

We have reviewed a wide range of roles and settings for CHW activities. The reality on the ground, however, is that most positions for CHWs are created with a limited range of roles in mind. Sometimes this limitation is dictated by a funding source, especially if the CHWs are employed in a research context, where their intervention is very narrowly defined.

However, CHWs often play multiple roles even during one encounter with an individual or family. They may, for example, shift from providing basic health education to providing resources and referral or counseling and social support. Most research studies do a poor job of capturing this range of activity and the ancillary benefits received by the individuals and families.

One exception is Ohio’s Community Health Access Program, or CHAP, now being replicated nationally as the “Community HUB/Pathways” model. CHAP began by serving pregnant women at high risk of premature and low-birth-weight delivery. The model uses a series of as many as 50 protocols, called “pathways,” for common situations CHWs encounter when working with these women. The pathways include some nonmedical issues, such as housing. As well as being a valuable guide to CHWs, the pathways link to the program’s data collection system. After working with a client, the CHW enters data into a tablet display formatted as a pathway flowchart. She can record her time and actions in that format, thereby capturing the nonmedical interventions that may contribute to a successful outcome.

Because of their high level of commitment to the communities they serve, CHWs often report taking action outside of their assigned duties because “that’s what the family needed.” This “whatever it takes” attitude may contribute significantly to their success, but it can often be difficult to identify a direct causal link between these actions and ultimate outcomes. This attitude may also translate into a resistance to strict service protocols, which can be problematic in programs based on research grants. One published study devoted significant attention to the ways in which open-ended CHW activities made it impossible to maintain the integrity of their strict research protocol. Some CHWs who were assigned to make a fixed number of home visits to each family simply made additional, unreported visits because they saw additional needs.

In the next few slides, we will address some of the management and supervisory challenges presented by the distinctive operating style of CHWs.